Knowledge, Attitude and Practice on Insecticide Treated Nets in Myanmar

453 International Journal of Collaborative Research on Internal Medicine & Public Health

San San Oo 1* , Zay Soe 2, Wana Hla Shwe 3

1 Senior Lecturer and Head of the Woman, Child and Family Health Department, UCSI University, Malaysia 2Associate Professor and head of the Internal Medicine Department, UCSI University, Malaysia 3Senior Lecturer, Internal Medicine Department, UCSI University, Malaysia

* Corresponding Author: San San Oo M.B.,B.S. M.Med.Sc (Public Health). MA(Population and Reproductive Health Research), IPSR (Mahidol University, Thailand). Senior Lecturer and Head of the Woman, Child and Family Health Department, UCSI University, Malaysia | Email [email protected]

Abstract

Introduction: In Myanmar, malaria problem has become more critical with the development of multi-drug resistance in P. falciparum. This development made the governments to focus their attention for building up vector control program based upon selective spraying, personal protection method, including Insecticide Treated Nets (ITNs) that can be carried out by the communities

Objectives: The present study is aimed to assess knowledge, attitude and practice of community on ITN in Myanmar.

Research Methdology: A cross-sectional descriptive study was done in 16 villages. A pre-tested structured questionnaire was used with face to face interview to 256 randomly selected households. Only one adult person was interviewed per household.

Results: The study results showed that more than three-fifth (62.1%) of the study population had low knowledge level on malaria and ITNs uses and some misconceptions regarding the mode of transmission of malaria. About two-thirds of the study respondents had low attitude score on malaria prevention and use of ITNs. There is significant association between knowledge and attitude level of respondents and their educational status.

Conclusion: This study show that there is a need for increasing availability of information on ITN and ITN tablets to prevent malaria transmission in the study township.

Key words: Malaria, knowledge attitude and practice (KAP), insecticide treated nets, Myanmar

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Introduction Malaria parasites are transmitted to humans by the bite of infected female mosquitoes of more than 30 anopheline species. Globally, an estimated 3.3 billion people were at risk of malaria in 2010, with populations living in sub-Saharan Africa having the highest risk of acquiring malaria: approximately 80% of cases and 90% of deaths are estimated occur in the WHO African Region, with children under five years of age and pregnant women most severely affected. Malaria is an entirely preventable and treatable disease, provided the currently recommended interventions are properly implemented. Vector control through the use of insecticide-treated nets (ITNs) is one of the preventable factor. 1

In Myanmar, malaria has been prioritized as the second priority disease. Like in other countries of South-East Asia Region, malaria was one of the major and re-emerging public health problems in Myanmar, due to climatic and ecological changes, uncontrolled population migration, development of multi-drug resistant P. falciparum parasite, development of insecticide resistant vectors and changes in behaviour of malaria vectors.2

In Myanmar, malaria problem has become more critical with the development of multi-drug resistance in P. falciparum, vector resistance of Dichloro Diethyl Trichloroethane (DDT) and Organo Phosphorous (OP) compounds of insecticides. This development made the governments to focus their attention for building up vector control program based upon selective spraying, personal protection method, including Insecticide Treated Nets (ITNs) that can be carried out by the communities themselves within the primary health care system in conformity with the global malaria control strategy of World Health Organization(WHO). There is no enough time and funding to study the behaviour of vector mosquitoes and vector resistance to insecticide. So, locally appropriate vector control strategy is needed to allow cost- effective vector control. The ITNs could be considered as an added tool in combating against malaria. 3

Since prevention is more effective than treatment, we have to emphasize on community awareness on insecticide treated nets. Therefore, it is necessary to know the knowledge, attitudes and practices of population on ITN.4

Knowledge, attitude and practice study on malaria was conducted by ORISSA voluntary health association, India in 1999. This study included 799 participants. They found that 100% respondents know about a disease called malaria. The respondents had good knowledge of signs and symptoms of malaria : highest of 81.51% of respondents identified fever as a symptom of malaria followed by head and body ache 43.90%, chills and rigors 14.38%, sweating 12.97% others 12.84% and vomiting 7.96% respectively. This study also showed that 67.14% of the respondents identified the cause of malaria as Mosquito bite. They also had few answers like malaria parasite, unsanitary environment, drinking unsafe water and others. 5 A descriptive cross-sectional survey was undertaken in Swaziland by Khumbulani et al at 2009 6. This study involved 320 randomly selected households. Of 320 households surveyed 289 (93.1%) of the respondents had heard about malaria with almost all of

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them correctly associating malaria with mosquito bites. The respondents identified symptoms such as headache, high fever and chills were three most frequently mentioned signs and symptoms. Knowledge about malaria treatment was high with 91.8% of the respondents stating that they would seek treatment in health facilities. Knowledge about malaria prevention among participant was high. Most respondents knew that clinics and vector control were important for treating and preventing malaria. With regard to personal protective measures some participants stated that they use bed nets followed by mosquito coils and to a lesser extent the burning of cow dung/leaves, repellents sprays and lotion, but a substantial number of them did not use anything. In India during 2008, a cross-sectional survey interview on 1130, 1012 and 126 respondents showed that the net use rate were 80%, 74% and 55% in the cold, rainy and summer seasons, respectively. Since using ITNs, 74.5-76.6% of the respondents observed reduction of mosquito bites and 7.2-32.1% reduction of malaria incidence; 37% expressed willingness to buy ITNs if the cost was lower and they were affordable. 7

Aim and Objectives Aim

To assess knowledge, attitude and practice on uses of Insecticide Treated Nets (ITNs) in Myanmar.

Objectives

• To assess knowledge about malaria, usefulness of bed net / ITNs, perception on uses of ITNs.

• To observe the ownership of bed net / ITNs.

• To identify treatment seeking behaviour for malaria.

Research Methodology Study design: Cross-sectional study design was used in this study.

Study area: This study was conducted in the area of Sa Lin Township, Magway division, Myanmar.

Study population: The study population was all heads of the selected household or in the absence of head of household those adult members who had completed 18 years of age in the selected household was eligible for the study.

Study period: Study period was in August, 2009.

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Sampling procedure: Two stages sampling procedure was done.

First stage:

Cluster sampling was done in selection of (16) villages, based on 3 criteria. These criteria were accessibility i.e. able to access by car within one hour, spread i.e. there is sufficient distance among selected villages for possible application of GPS, to include both high and low prevalence villages.

Second stage:

Selection of 16 households from each village by systematic random sampling method.

Sample size determination 2 2

90% Power = 1.28

2, 3 Po = 0.7

2, 3 Pa = 0.6

Po = observed prevalence

Pa = expected prevalence

= 0.1 2 2

n = 232.6

Data collection method

Data collection was conducted by face to face interview using the pre-tested semi- structured questionnaire. Questionnaires were developed from reviewing the literature. The questionnaires were pre-tested in Thanlyin Township. The respondents included in the study were first informed of the purpose of the research and the consent was taken prior to the interview. If the respondents did not agree to be

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interviewed after the full comprehension of the research, they were excluded in this study.

Data entry, cleaning and analysis

Data entry and data cleaning were done by applying Epi-data version 3.2. Data analysis using chi-square test was done by Statistical Package for Social Science (SPSS) version 16.0 and Microsoft office excel.

Results Socio-demographic characteristics

Socio-demographic characteristics of respondents

Out of 256 respondents, 44.9% were males and 55.1% were females. The ages for the respondents in the selected households ranged from 18 years to 85 years with the mean, median and standard deviation of 44.5, 43 and 13.9 respectively.

Half of the respondents (50%) had medium educational status which includes primary school passed and middle school passed. About 39% had low educational status which includes illiterate and read and write. About 11% of the respondents had high educational status which includes high school passed and graduated. More than half of the respondents were farmers. (Table 1)

Knowledge about Malaria

Knowledge on awareness of Malaria

Majority of the respondents 98.8% (n=253) had heard about Malaria and only 3 of them had not. (Table 2)

Knowledge about signs and symptoms of Malaria

Chills and rigor and intermittent fever were the two most commonly mentioned signs and symptoms of Malaria 74.1% (n=189) and 60.4% (n=154) respectively. Only 10% and less were headache, fever, others and don’t know about signs and symptoms of Malaria. (Figure 1)

Knowledge about complications of Malaria

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42.6% (n=103) of the respondents were aware of Cerebral Malaria as complication of Malaria. Fatigue, cyanosis and bleeding from nose were commonly mentioned responses in others category. 37.2% did not know complications of Malaria at all. (Figure 2)

Knowledge about mode of transmission of Malaria

Majority of the respondents (83.1%, n=202) were aware that Malaria could be transmitted by mosquito bites. Only one respondent (0.4%) could answer that Malaria could be transmitted by blood transfusion. None of them knew that Malaria could be transmitted from pregnant mother to foetus. There were misconceptions regarding the mode of transmission of Malaria such as drinking of spring water, eating of banana and lack of personal hygiene. Most common responses in others category were drinking of unclean water and change in weather. (Table 3)

Knowledge on persons at risk of Malaria

102 out of 256 respondents interviewed correctly stated that those persons travelling to Malaria endemic area were at risk of getting Malaria. Young children, weak persons and those who slept without bed nets were common responses in others category of high risk persons to Malaria. (Table 4)

Knowledge about methods of prevention from mosquito bite

Knowledge about methods of prevention from mosquito bite was dichotomised into correct responses (which includes sleeping inside bed net, sleeping inside ITNs, using mosquito coils, using mosquito repellents, using spray, using fumigation) and incorrect responses ( which includes drinking of boiled water, don’t know, environmental factors and others).

Out of 256 respondents interviewed, 231 (90.9%) responded that sleeping inside bed net could prevent mosquito bite. 45.7% stated mosquito coils and 17.3% mentioned ITNs to prevent mosquito bite. Only 17.3% answered that they would sleep inside ITNs to prevent mosquito bite. (Table 5)

Knowledge about methods of prevention from Malaria

Knowledge about methods of prevention from Malaria was dichotomised into correct response and incorrect response.

About 70% (n=168) of the respondents could correctly answer that Malaria could be prevented by sleeping inside bed net and only 11.2% (n=27) stated that ITN could be used to prevent Malaria. Majority of incorrect response was preventing Malaria by

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drinking of boiled water 14.1% (n=34). Over 20% of respondents said that Malaria could be prevented by environmental measures such as regular change of water from flower pots and cleaning of bushes. (Table 6)

Knowledge on Insecticide Treated Nets

Knowledge on Insecticide Treated Nets (ITNs) and Insecticide Tablets

Out of 256 respondents studied, 166 (64.8%) had heard about ITNs. Among them, 45.3% could answer the life span of ITNs. Although 174 (68.0%) of the respondents had heard about ITN tablets, most of the respondents did not know where they could buy the ITN tablets (83.6%). (Figure 3)

Responses to the life-span of ITNs were grouped into those stated as shorter than 6 months, 6-9 months (correct statement) and as above 6 months. 26.2% (n=67) of the respondents had stated that life-span of ITN was 6 months. One respondent stated as 60 months (maximum) and another one as zero month (minimum). Only 28.1% could correctly answer the life span of ITNs as 6-9 months. ( Figure 4)

Knowledge Level

There were nine questions to study the knowledge status of respondents. We gave one score for each correct response. Possible total score was 28. Minimum score was 0 (zero), maximum score was 20, mean score was 7.9 and median score was 8. Most of respondents could answer up to score 8 (i.e. mode score is 8). Therefore, knowledge status of respondents was categorized into low knowledge level (knowledge score less than 8), medium knowledge level (knowledge score = 8) and high knowledge level (knowledge score above 8). In this study, 48% of the respondents had low knowledge and 38% of the respondents had high knowledge. (Table 7) and (Figure 5).

Attitude

Attitude on malaria prevention and ITNs

Out of 256 respondents, 133(52.0%) correctly perceived that malaria could be prevented even if one is residing in malaria endemic area. 139 (54.3%) correctly perceived that malaria could be prevented if one is sleeping inside mosquito net. 221(86.7%) correctly believed that sleeping inside ITN at night reduces mosquito bite. 182 (71.1%) correctly perceived that sleeping inside ITN at night reduces bedbugs and lices. 192(75%) of the respondents expressed willingness to buy ITNs if they did not get free. (Table 8)

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4.2 Attitude level

There were five questions to study the attitude status of respondents. We gave one score for each correct response. Possible total score was 5. Minimum score was 0 (zero), maximum score was 4, mean score was 2.5 and median score was 3. Most of respondents could answer up to score 3 (i.e. mode score is also 3). Therefore, attitude status of respondents was categorized into low attitude level (attitude score less than 3), medium attitude level (attitude score = 3) and high attitude level (attitude score above 3). Among 256 respondents, 45.3% got low score and 25% got high score. . (Table 9) and (Figure 6).

V. Practice on prevention of malaria

5.1 Practice on use of bed nets and ITNs

97.7% of the respondents owned bed nets and 94% had habit of sleeping inside bed nets. Only 16% of total respondents had ITNs in their households and 88% of them had habit of sleeping inside ITNs (14.1% of total). (Figure 7)

Average ownership of bed nets was 3.1 and 0.35 ITNs per house hold. Average number of household members slept inside bed nets was 4.6 and that of household members slept inside ITNs was 0.6. (Table 10)

5.2 Practice level

There were five questions to assess the practice level of the respondents. We gave one score for each correct response. Possible total score was 4. Minimum score was 0 and maximum was 4. Mean score was 2.22 and medium was 2. Most of respondents (79.3%) could answer up to score 2(i.e. mode score is also 2). Therefore, practice status of respondents was categorized into low practice level (practice score less than 2), medium practice level (practice score = 2) and high practice level (practice score above 2). Among 256 respondents, 45.3% got low score and 25% got high score. (Table 11)

Table 12 shows relationship between history of malaria and bed net ownership. Out of 102 Malaria cases, 2 (2%) did not have bed nets. Although 86 (95.6%) of 90 Malaria cases did not have ITNs, there was no statistically significant association between ITN ownership and history of Malaria in the household (p = 0.538).

Among 8 cases with history of Malaria in the family, 6 (75.0%) did not sleep under bed net last night. Among 88 cases with history of Malaria in the family, 87(98.9%) did not sleep inside ITNs last night. There was no statistically significant association between sleeping habit inside bed nets or ITNs and history of Malaria in the household. (Table13).

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5.3 Reasons for not using ITN

Out of 256, 221 (who were not using ITNs) gave reasons why they didn’t use ITNs as follow: 69 (31.2%) did not know about ITNs, 67(30.3%) do not have ITNs, 32 (14.5%) could not afford to buy ITNs, 7(3.2%) were dislike to use. Most of others reasons were didn’t know where they could buy ITN tablets and not having the habit of sleeping inside ITNs. (Figure 8)

Treatment seeking pattern on malaria

51.2% of the respondents answered that they would consult with basic health staffs (such as Midwife, Health Assistant, Station Medical Officer and Township Medical Officer) if there was any Malaria case in their families. The rest would consult with GP (23.1%), folk medicine (12.7%), traditional medicine (5.2%) and self treatment (7.7%). (Figure 9)

Association between Socio-demographic characteristics and KAP of respondents

Association between Socio-demographic characteristics and knowledge on malaria and ITN

Table 14 shows association between Socio-demographic characteristics and knowledge on malaria and ITN.

Most of respondents with low educational status had low knowledge level on Malaria (46.9%) and those with high educational status had high knowledge level (64.3%). There was statistically significant association between educational status of respondents and knowledge (x2 = 14.855, p = 0.005).

Association between Socio-demographic characteristics and attitude on malaria prevention and ITN usage

Most of respondents with low educational status had low attitude level on Malaria prevention and ITNs (57.0%) and there was statistically significant association between educational status of respondents and attitude (x2 = 11.844, p = 0.019). (Table 15)

Association between Socio-demographic characteristics and practice score

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There was no statistically significant association between socio-demographic characteristics and practice score. (Table 16)

Association between respondents’ knowledge and attitude

Table (17) shows association between respondents’ knowledge and attitude. There was statistically significant association between respondents’ knowledge and attitude. (x2 = 27.661, p = 0.000).

Association between respondents’ knowledge and practice

Table (18) shows association between respondents’ knowledge and practice. There was no statistically significant association between respondents’ knowledge and attitude. (p = 0.541).

Association between respondents’ attitude and practice

Table (19) shows association between respondents’ attitude and practice. There was no statistically significant association between respondents’ attitude and practice. (p = 0.090).

Discussion Knowledge status of respondents

In this study, majority of the respondents had heard about malaria. But they had limited knowledge about signs and symptoms of malaria and the severe malaria. Most of them recognized chills and rigor and only a few of them could mention headache and sweating as signs and symptoms of Malaria. Their perceived severity regarding complications was mostly cerebral malaria and dead.

More than two-third (83.1%) of the study respondents were aware that mosquito bites as the mode of malaria transmission. However, there were misconceptions about mode of malaria transmission such as drinking of spring water, eating banana and lack of personal hygiene.

Although most of them (69.7%) believed that sleeping inside bed nets could prevent malaria, very few of them (11.2%) aware that sleeping inside ITNs could prevent malaria.

Although it seemed to be related that high income level and high knowledge level, there was no statistically significant association between income level and knowledge level (p=0.537).

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Education clearly influence the knowledge level on Malaria showing low educational status group had more proportion of low knowledge level (57%) and educated respondents had high knowledge level (64.3%). It is statistically significant (p=0.001).

In this study, 48% of respondents had low knowledge level and 38% had high knowledge level. This might be due to low literacy rate of respondents because 50% of them had attained primary or middle school passed, 39.1% were illiterate or could read and write and only 10.9% were high school passed or university students or graduated.

Attitude status of respondents

During survey, positive attitude on malaria and ITNs was found in more than half of respondents. There is no statistically association between socio-demographic characteristics and using of ITNs, except in education .Although there was high proportion (45.8%) of low attitude status group in primary and middle school passed respondents, there was statistically significant association between education and attitude status. (p = 0.048)

Practice on bed nets and ITNs

Although ownership of bed net was high, ownership of ITN was relatively low. Sleeping under ITNs was relatively much lower than bed net. Among those who did not use ITNs, most common reasons were do not know and do not have ITNs.

There is no significant association between ownership of bed net, ITNs and Malaria, probable cause may be due to small sample size. There is no statistically significant association between history of fever and sleeping inside of bed nets or inside ITNs, but those who did not sleep inside ITNs suffered fever (4) times than who slept inside ITNs.

There is a need for improving the availability of information through the preferred community channels as well as professional health routes.

On interviewing treatment seeking behaviour, about half of respondents stated that they would consult with health personal for malaria.

Conclusion In conclusion, most respondents showed an understanding of malaria transmission. But there were significant misconceptions about modes of malaria transmission. Knowledge on ITNs as a tool for prevention of malaria was observed to be low (11.2%) among the study population.

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In this study, most of the respondents had low attitude level about malaria and ITNs (75%). Although bed net ownership among the study population high, ITNs ownership was found to be low. Sleeping habit inside bed net was found to be high.

Major cause of low habit of sleeping inside ITNs was due to lack of awareness and due to unavailability to buy ITNs (nearly 30% each).

There was limited access to health information regarding ITNs, ITN tablets, their sources and life-span. These results call for targeted health education or communication to increase the population’s knowledge on ITNs and ITN tablets.

Treatment seeking pattern on Malaria was found to be fair enough as the study participants answered that they would consult with Basic Health Staff if there was any Malaria case in their families (51.2%) and 23.1% with General Practitioner.

Recommendations Community awareness on mode of transmission of Malaria should be improved. Utilization of ITNs should be strengthened by means of regular and periodic health education and behavioral change communication on use of ITNs. The existing treatment seeking pattern on Malaria should be maintained and improved. Educational status of the community should be improved and the practice on use of ITNs should be empowered.

Conflict of Interest: None declared.

References

1. World malaria report 2012: World Health Organization (WHO). ISBN 978 92 4 156453 3 (NLM classification: WC 765) 2. Health in myanmar (2009) published by Ministry of Health, Myanmar 3. Dr. Thar Htun Kyaw .A study on effectiveness of Utilization of Insecticide Treated Mosquito Net on Malaria in Kayah State, Myanmar (2004). 4. Audrey Pettifor, Eboni Taylor, David Nku, Sandra Duvall, Martine Tabala, Steve Meshnick and Frieda Behets. Bed net ownership, use and perceptions among women seeking antenatal care in Kinshasa, Democratic Republic of Congo(DRC): Opportunities for improvedmaternal and child health. BMC Public Health 2008, 8:331 doi:10.1186/1471-2458-8-331 5. Mr. Himanasu Sekhar Dutta KAP study on Malaria in project areas of malaria centres of OVHA (Orissa Voluntary Health Association).Journal of Pharmaceutical and Biomedical Sciences (JPBMS) 2012 Vol 23, Issue 23; pp1-3 6. Khumbulani W Hlongwana , Musawenkosi LH Mabaso , Simon unene , Dayanandan Govender and Rajendra Maharaj. Community knowledge, attitudes and practices (KAP) on malaria in Swaziland: A country earmarked for malaria elimination. Malaria Journal 2009, 8:29 doi:10.1186/1475-2875-8-29

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7. P Jambulingam; K Gunasekaran, SS Sahu; T Vijayakumar. Insecticide treated mosquito nets for malaria control in India-experience from a tribal area on operational feasibility and uptake. Mem Inst Oswaldo Cruz, Rio de Janeiro, 103(2) March 2008. PP165-171 DOI: S0074-02762008000200007

Table (1) Socio-demographic characteristics of respondents in the study households

Characteristics No (n= 256) % Gender • Male 115 44.9 • Female 141 55.1 Age group • <= 40 years 108 42.2 • > 40 years 148 57.8 Race • Bamar 253 98.8 • Others 3 1.2 Marital status • Single 31 12.1 • Married 221 86.3 • Others 4 1.6 Education Low 100 39.1 • Illiterate 15 5.9 • Read & write 85 33.2 Medium 128 50 • Primary school passed 89 34.8 • Middle school passed 39 15.2 High 28 10.9 • High School passed 13 5.1 • College/Graduated 15 5.9 Occupation • Farmer 139 54.3 • Dependent 27 10.5 • Small business 57 22.3 • Manual labour 23 9.0 Government staff 10 3.9

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Table (2) Knowledge on awareness of Malaria

Heard about Malaria No. (n=256) %

Yes 253 98.8

No 3 1.2

Table (3) Knowledge about mode of transmission of Malaria Mode of transmission No.(n=256) % Correct response Mosquito bite 202 83.1 Blood Transfusion 1 0.4 Mother to child transmission 0 0

Incorrect response Drinking of Spring water 41 16.9 Going into forest 24 9.9 Eating Banana 15 6.2 Lack of personal Hygiene 14 5.8 Others 42 16.4 Don't know 23 9.5

Note: Total percentage may be more than 100% due to multiple responses.

Table (4) Knowledge on persons at risk of Malaria Risk persons No.(n=256) %

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Correct response Travelling to malaria endemic area 102 39.8 Travelling to forest/ mountainous area 88 34.4

Incorrect response Others Don't know 72 28.1 55 21.5

Note: Total percentage may be more than 100% due to multiple responses.

Table (5) Knowledge about methods of prevention from mosquito bite Methods No.(n=256) % Correct response Sleeping inside bed net 231 90.9 Using the mosquito coils 116 45.7 Sleeping inside ITNs 44 17.3 Using fumigation 22 8.7 Using spray 18 7.1 Using mosquito repellent 12 4.7

Incorrect response Environmental factors 51 20.1 Drinking of boiled water 3 1.2 Others 19 7.4 Don't know 4 1.6

Note: Total percentage may more than 100 % due to multiple responses.

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Table (6) Knowledge about methods of prevention from Malaria Methods No.(n=256) % Correct response Sleeping with bed net 168 69.7 Using the mosquito coils 38 15.8 Sleeping with ITNs 27 11.2 Using spray 9 3.7 Using fumigation 8 3.3 Using mosquito repellent 5 2.1

Incorrect response Environmental factors 50 20.7 Drinking of boiled water 34 14.1 Others 38 14.8 Don't know 46 19.1

Note: Total percentage may more than 100 % due to multiple responses.

Table (7) Knowledge level of respondents Knowledge score on malaria and ITN No.(n=256) % Low (score < 8) 123 48 Medium (score = 8) 36 14 High (score > 8) 97 38 Total 256 100

Table (8) Attitude on malaria prevention and ITNs Agree Disagree Don’t know Total No. % No. % No. % No. % Malaria could not 73 28.5 133 52.0 50 19.5 256 100 be prevented if one is living in malaria endemic area Sleeping inside 84 32.8 139 54.3 33 12.9 256 100 mosquito nets at night does not prevent malaria Sleeping inside 222 86.7 5 2.0 29 11.3 256 100 ITNs at night reduces mosquito bite

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Sleeping inside 182 71.1 11 4.3 63 24.6 256 100 ITNs at night reduces bedbugs and lice If ITN will not get 192 75 36 14.1 28 10.9 256 100 free, I will buy

Table (9) Attitude level of respondents on malaria prevention and ITNs Attitude score on malaria prevention and ITNs No.(n=256) % Low (score ≤ 3) 116 45.3 Medium (score = 3) 76 29.7 High (score > 3 ) 64 25.0 Total 256 100

Table (10) Ownership and use of bed net and ITNs Mean ± SD Range Median (min-max) No. of bed net 3.1 ± 1.7 0 – 12 3 No. of ITNs 0.3 ± 0.9 0 – 5 0 No. of household slept under 4.6 ± 2.2 0 – 12 5 bed net last night No. of household slept under 0.6± 1.6 0 – 9 0 ITNs last night

Table (11) Practice level of respondents on malaria prevention and ITNs Attitude score on malaria prevention and ITNs No.(n=256) % Low (score ≤ 2) 13 5.0 Medium (score = 2) 203 79.3 High (score > 2 ) 40 15.7 Total 256 100

Table (12) Relationship between history of Malaria in the household and bed net ownership Malaria Bed nets(+/-) Yes No No. % No % Yes 100 98.0 150 97.4 No 2 2.0 4 2.6 p = 0.548 (Fisher’s exact probability test) ITNs(+/-) Yes 4 4.4 7 5.1

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No 86 95.6 129 94.9 p = 0.538 (Fisher’s exact probability test)

Table (13) Relationship between Malaria and sleeping inside bed-nets and ITNs Malaria Sleeping with bed Yes No nets No. % No % Yes 2 25.0 3 25.0 No 6 75.0 9 75.0 p = 0.704 (Fisher’s exact probability test) Sleeping with ITNs Yes 1 1.1 1 0.7 No 87 98.9 133 99.3 p = 0.637 (Fisher’s exact probability test)

Table (14) Association between socio-demographic characteristics of respondents and knowledge on Malaria and ITNs Socio-demographic Knowledge (n=256) Characteristics of Low(<8) Median( = 8) High(>8) x2 Test respondents No. % No. % No. % Age <=40yrs 45 41.7 15 13.9 48 44.4 p = 0.157 > 40yrs 78 52.7 21 14.2 49 33.1 Gender Male 51 44.3 16 13.9 48 41.7 p = 0.493 Female 72 51.1 20 14.2 49 34.8

Race Bamar 123 48.6 36 14.2 94 37.2 p = 0.083 Others 0 0 0 0 3 100.0

Marital status Single 15 48.4 7 22.6 9 29.0 Married 105 47.5 29 13.1 87 39.4 p = 0.425 Others 3 7.5 0 0 1 25.0 Educational status Low 57 57.0 16 16.0 27 27.0 * Median 60 46.9 16 12.5 52 40.6 p=0.005 High 6 21.4 4 14.3 18 64.3 x2 =14.855

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Occupation Currently working 109 47.6 31 13.5 89 38.9 p = 0.588 Dependent 14 51.9 5 18.5 8 29.6

Annual family income <=600,000kyats 64 48.1 21 15.8 48 36.1 p = 0.662 > 600,000kyats 59 48.0 15 12.2 49 39.8

Note: * = Statistically significant at p = 0.05 level

Table (15) Association between socio-demographic characteristics and attitude score Socio-demographic Attitude Characteristics of Low(<3) Median(3) High(>3) x2 Test respondents No. % No. % No. % Age <=40yrs 46 42.6 32 29.6 30 27.8 p = 0.643 > 40yrs 70 47.3 44 29.7 34 23.0 Gender Male 48 41.7 38 33 29 25.2 p = 0.5 Female 68 48.2 38 27 35 24.8

Marital status Single 10 32.3 12 38.7 9 29.0 p = 0.13 Married 102 46.2 64 29.0 55 24.9 Others 4 100 0 0 0 0 Educational status Low 57 57.0 26 26.0 17 17 *p = 0.019 Median 50 39.1 38 29.7 40 31.2 x2 = 11.844 High 9 32.1 12 42.9 7 25 Occupation Currently working 99 43.2 71 31.0 59 25.8 P=0.146 Dependent 17 63.0 5 18.5 5 18.5

Annual family income <=600,000kyats 62 46.6 41 30.8 30 22.6 P=0.642 > 600,000kyats 54 43.9 35 34 34 27.6

Note: * = Statistically significant at p = 0.05 level

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Table (16) Association between socio-demographic characteristics and practice score Socio-demographic Practice (n=256) Characteristics of Low(<2) Median(2) High(>2) x2 Test respondents No. % No. % No. % Age <=40yrs 7 6.5 86 79.6 15 13.9 p = 0.581 > 40yrs 6 4.1 117 79.1 25 16.9 Gender Male 7 6.1 85 73.9 23 20.0 p = 0.154 Female 6 4.3 118 88.7 17 12.1

Race Bamar 13 5.1 200 79.1 40 15.8 p = 0.673 Others 0 0 3 100.0 0 0

Marital status Single 5 16.1 20 64.5 6 19.4 Married 8 3.6 180 81.4 33 14.9 p = 0.083 Others 0 0 3 75.0 1 25.0

Educational status Low 7 7.0 78 78.0 15 15.0 Median 4 3.1 105 82.0 19 14.8 p = 0.564 High 2 7.1 20 71.4 6 21.4 Occupation Currently working 12 5.2 179 78.2 38 16.6 p = 0.413 Dependent 1 3.7 24 88.9 2 7.4

Annual family income <=600,000kyats 8 6.0 104 78.2 21 15.8 p = 0.769 > 600,000kyats 5 4.1 99 80.5 19 15.4

Table (17) Association between respondents’ knowledge and attitude Attitude (n=256) Total Knowledge Low (<3) Medium(=3) High(>3) % Low(<8) 58.5 26.8 14.6 100 Medium(=8) 50.0 30.6 19.4 100 High(>8) 26.8 33.0 40.2 100

Vol. 5 No. 6 (2013) 473 International Journal of Collaborative Research on Internal Medicine & Public Health

Table (18) Association between respondents’ knowledge and practice Practice (n=256) Total Knowledge Low (<2) Medium(=2) High(>2) % Low(<8) 6.5 77.2 16.3 100 Medium(=8) 2.8 75.0 22.2 100 High(>8) 4.1 83.5 12.4 100

Table (19) Association between respondents’ attitude and practice Practice (n=256) Total Attitude Low (<2) Medium(=2) High(>2) % Low(<3) 7.8 80.2 12.0 100 Medium(=3) 2.6 73.7 23.7 100 High(>3) 3.1 84.4 12.5 100

80 70 60 50

40 30

% of respondents 20 10 0 Chills & Rigor Intermittent Headache Sweating Others Don't know fever Signs and symptoms

Figure (1) Knowledge about signs and symptoms of Malaria

Vol. 5 No. 6 (2013) 474 International Journal of Collaborative Research on Internal Medicine & Public Health

45 40 35 30 25 20 15

% of respondents 10 5 0 Cerebral Death Coma Delirium Convulsion Others Don't known Malaria Signs and symptoms

Figure (2) Knowledge about complications of Malaria

80 70 60 50

40 30

% of respondents 20 10 0 Knowledge on ITNs Knowledge on ITN Knowledge on source Knowledge on life- tablets of ITN tablets span of ITNs Knowledge

Figure (3) Knowledge on awareness of the existence of ITNs and Insecticide Tablets

Vol. 5 No. 6 (2013) 475 International Journal of Collaborative Research on Internal Medicine & Public Health

20 % of% respondents

0 <6 months 6-9 months >9 months Life span of ITN

Figure (4) Knowledge on life-span of ITNs

Figure (5) Box and plot of Knowledge score

Vol. 5 No. 6 (2013) 476 International Journal of Collaborative Research on Internal Medicine & Public Health

Figure (6) Box and plot of Attitude score

120 97.7 100 94.1

80 60

40 16 14.1 % of the respondents 20

0 Bed nets Slept with bed net ITNs Slept with ITNs previous night previous night

Practice

Figure (7) Practice on use of bed nets and ITNs

Vol. 5 No. 6 (2013) 477 International Journal of Collaborative Research on Internal Medicine & Public Health

35 31.2 30.3 30 25 20.8 20 14.5 15

% of the respondents 5 3.2 0 Unawareness Inavailability Unaffordability Dislike Others Reasons

Figure (8) Reasons for not using ITNs

Traditional medicine 5.2

Self Treatment 7.7

Folk medicine 12.7

Consult with GP 23.1

Treatment seeking pattern Consult with BHS 51.2

0 10 20 30 40 50 60

% of the respondents

Figure (9) Treatment seeking behaviour of Malaria

Vol. 5 No. 6 (2013)